Patient Financial Clearance Representative I (Remote)

LE0010 Stanford Health Care; United States; Remote; USD 47,000 - 53,000; Full time

Job summary

Stanford Health Care is seeking a Patient Financial Clearance Representative to verify insurance coverage and obtain required authorizations. You will work under supervision within the Department Management and Patient Financial Clearance Lead to coordinate with clinics and payors.

The role requires familiarity with payer requirements, Medicare, Medi-Cal, Workers Compensation, and managed care plans, plus knowledge of relevant state and federal regulations. High school diploma or GED is required.

Qualifications

• High School diploma or GED equivalent.
• 1 year working knowledge of patient registration, insurance verification and authorization processes in a medical organization.
• Epic experience preferred.

Responsibilities

• Completes insurance verification, eligibility and benefit determination using electronic eligibility system, payer websites, and phone for all plans in scope.
• Interprets co-pay, deductible, share of cost, co-insurance and maximum benefit levels.
• Contacts patient to obtain updated information when necessary.
• Completes Medicare Secondary Questionnaire as appropriate.
• Applies authorization rules for all payors within the work queues.
• Develops knowledge of procedures and diagnoses to ensure proper authorizations.
• Assesses data required for authorization and sponsorship.
• Communicates with clinics and providers to obtain information for authorization.
• Follows up on pending authorizations and referrals to ensure timely completion.
• Escalates issues to receive peer-to-peer reviews when needed.
• Prioritizes work to minimize financial risk and meet productivity goals.
• Identifies risk related to coverage and benefit issues and escalates.

Skills

Insurance verification

Authorization processing

Payer communications

Education

High School diploma or GED

Tools

Epic

Job description

A Brief Overview

The Patient Financial Clearance Representative, under direct supervision of the Department Management and Patient Financial Clearance Lead, performs specialized functions for SHC patients by completing all activities related to insurance verification and securing authorization. These activities are performed in accordance with established Stanford Health Care regulations, policies, and procedures. The Patient Financial Clearance Representative has knowledge of healthcare payers, such as Medicare, Medi-Cal, Workers Comp, and all Managed Care plans as well as State and Federal regulations.

Locations

Stanford Health Care

What you will do

• Completes insurance verification, eligibility and benefit determination process utilizing integrated electronic eligibility system, payer websites, and phone for all insurance plans within the scope of the patient financial clearance department and assigned service line.
• Interprets and documents the appropriate co-pay, deductible, share of cost, co-insurance, maximum benefit levels and/or available days.
• Contacts patient as appropriate to obtain correct and updated information when necessary.
• Completes Medicare Secondary Questionnaire as appropriate.
• Applies authorization rules and requirements for all payors within the assigned work queues.
• Develops a strong working knowledge of the procedures and diagnosis used in the assigned service-lines to ensure authorizations are properly completed for the scope of services that will be rendered to the patient.
• Assesses the data required for authorization and securing sponsorship.
• Communicates with respective clinics and referring providers to secure appropriate information to complete an authorization.
• Follows up on pending authorization and referral requests to ensure timely completion and secured sponsorship for cases in the assigned work queue.
• Arranges escalation process for clinics and clinicians to complete peer-to-peer appeal reviews with payor utilization management when needed.
• Prioritizes work assigned to them to ensure that financial risk is minimized, and timely completion of authorizations is optimized, while meeting daily productivity measure goals.
• Identifies risk associated with coverage and benefit issues related to the services that are being requested for authorization and escalates these issues to appropriate experts to address.
• Identifies risk associated with securing financial clearance prior to service date and escalates to clinic and other resources to find an appropriate course of action (e.g. reschedule, cancel, sign PAFR).
• Understands the role of financial counseling in securing clearance for cases that do not have authorization secured timely.
• Properly refers these cases as appropriate.
• Notifies the department manager with issues, instances of errors, or obstacles to successful completion of work.
• Applies strong writing skills to account documentation, email communication and internal notes/memos.
• Manages outbound and inbound phone calls.
• Responds promptly to customer inquiries.
• Assists team coordinator and department manager with special projects as needed.
• Serves as a resource for other payor authorization teams.
• Performs other duties and responsibilities as assigned by the Department.

Education Qualifications

High School diploma or GED equivalent

Experience Qualifications

One (1) year working knowledge of patient registration and insurance verification and authorization processes in a medical organization Epic experience preferred

Licenses and Certifications

None

These principles apply to ALL employees:

SHC Commitment to Providing an Exceptional Patient & Family Experience

Stanford Health Care sets a high standard for delivering value and an exceptional experience for our patients and families.

Candidates for employment and existing employees must adopt and execute C-I-CARE standards for all of patients, families and towards each other.

C-I-CARE is the foundation of Stanford’s patient-experience and represents a framework for patient-centered interactions.

Simply put, we do what it takes to enable and empower patients and families to focus on health, healing and recovery.

You will do this by executing against our three experience pillars, from the patient and family’s perspective:

• Know Me: Anticipate my needs and status to deliver effective care
• Show Me the Way: Guide and prompt my actions to arrive at better outcomes and better health
• Coordinate for Me: Own the complexity of my care through coordination

Equal Opportunity Employer

Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.

Base Pay Scale:

Generally starting at $34.40 - $38.72 per hour

The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.

At Stanford Health Care, we seek to provide patients with the very best in diagnosis and treatment, with outstanding quality, compassion and coordination. With an unmatched track record of scientific discovery, technological innovation and translational medicine, Stanford Medicine physicians are pioneering leading edge therapies today that will change the way health care is delivered tomorrow. As part of our spirit of discovery, we also leverage our deep relationships with luminary Silicon Valley companies to develop new ways to deliver preeminent patient care.